Perfecting Compression with Peak Performance

1
Perfecting Compression with Peak Performance

• Chairperson
• Professor Christine Moffatt
• Professor of Nursing and Director of the Centre
  for Research and Implementation of Clinical
  Practice, London.

2
Compression and Performance reference points

• Irene Anderson
• Harrogate 2008

3
Objectives

• Laplaces law
• Static stiffness index
• Compression therapy in practice
• Conclusion

4
Laplaces Law

• P TN x 472
• CW
• P pressure
• T bandage tension
• C limb circumference
• W bandage width
• N number of layers

5
P. LA. C .E (Partsch, Clark et al, 2008)

• Pressure
• Layers
• Components
• Elastic
• Composite bandages elasticity and performance

6
Static Stiffness Index

• Interface pressure increase per cm of
  circumference increase at B1(Partsch, 2005)
• Pressure measured at rest when circumference is
  minimal and on standing when circumference is
  maximised (standing- supine SSI)
• Combining materials/new materials changes the
  definitions of elastic and inelastic
• Classification terms should only be used for
  single components
• SSI depends on combination and internal friction
  in the layers

7
Static Stiffness Index measurement point
The circumference difference is assumed as
1cm Stolk et al, 2004 Mosti Mattaliano, 2007
B1
8
Supine to Standing (Partsch et al, 2008)
10mmHg defines
inelasticity

• Elastic components can behave inelastically in
  combination
• Friction between surfaces
• Friction in adhesive and cohesive layers

9
Compression Therapy in Practice

• Application skills
• Limb shape

10
Compression Therapy in Practice
Treatment objectives
Patient comfort Patient choice
11
Compression Therapy in Practice

• Compression may deliver similar resting pressures
• Higher working pressure (standing/walking)
  reduces hydrostatic pressure
• High SSI more effective in oedema control and
  venous reflux
• Combinations of materials may produce a high SSI

12
Conclusion

• Bandages may perform differently in combination
• The static stiffness index indicates performance
• Classification systems need to indicate bandage
  performance profiles
• Manufacturers need to include SSI performance
  indicators
• Assessment and application skills still matter!

13
References

• Partsch H (2005) The static stiffness index a
  simple method to assess the elastic property of
  compression material in vivo Dermatologic surgery
  31 625-630
• Partsch, H, Clark M, Mosti, G et al (2008)
  Classification of compression bandages practical
  aspects. 34 600-609
• Stolk R, Wegen van der-Franken CPM, Neumann HAM
  (2004) A method for measuring the dynamic
  behavior of medical compression hosiery during
  walking. Dermatologic Surgery 30 729-736
• Mosti GB, Mattaliano V (2007) Simultaneous
  changes of leg circumference and interface
  pressure under different compression bandages.
  European Journal of Vascular and Endovascular
  Surgery. 33 476-482

14
Peak Performance an exploration of the facts

• Kerihuel JC (MD, PhD) Presenter
• Benigni JP (MD) Investigator

15
K TWO system and study objective

• K TWO a two layer system
• K TECH extensibility 60 ? 10
• K PRESS extensibility 160
• Is there a need to adapt the system to ankle
  diameter ?
• Are the interface pressures adequate with K
  TWO whatever the ankle circumference?

16
Study design

• Open, unicentric study

17
Compression system
18
Patients

• 24 (7 males and 17 females) adult patients
  included.
• CEAP class C1A, C0S or C1S ABPI value ? 0.9
• No skin/wound problems
• No venous reflux on saphenous and
  femoro-popliteal axes
• Mean ( SD) age 39 16 (19 to 66 years)
• Mean BMI (kg/m2) 25.1 4.2 (19.3 to 34.4 kg/m2)
• 12 patients ankle ?25 cm (23.7 1.0 22 to 25
  cm)
• 12 patients ankle 25 cm (28.0 1.8 26 to 31 cm)

19
Results Pressure T0
Supine
Standing
20
Results - Pressure at T30
Supine
Standing
21
Pressure Loss

• Pressure loss is associated with a large
  reduction in leg volume, seen not only with
  oedematous legs but also in healthy legs
• This volume reduction is explained by
• an increased re-absorption of fluid from the
  tissues into the blood capillaries
• a shift into the proximal, non-compressed parts
  of the upper leg

Damstra RJ et al. 2008
22
Pressure loss T30/T0 (Supine Standing)
Supine
Standing
23
The therapeutically intended volume reduction
Supine
Standing
24
Static Stiffness Index

• The elasticity of a compression bandage may be
  characterized by its stiffness
• In the European Standard for medical compression
  hosiery (CEN), stiffness is defined as the
  increase in pressure per 1 cm increase in leg
  circumference
• This is the theory behind the measurement of
  pressure at a defined position on the lower leg
  at rest (circumference is minimal) and at the
  same spot, when the circumference has maximally
  increased (muscle contraction during active
  standing)

Partsch H. 2005
25
SSI (2)

• At rest (supine)
• Standing up (muscularcontraction)
• Change in leg circumference ? 1 cm (large
  variations)

26
SSI (3)
27
Conclusions

• K TWO is an efficient compression system
• Interface pressures and bandage stiffness remain
  similar whatever ankle circumference and without
  system adaptation i.e. additional layers
• This simplifies bandage selection and
  application and represents an important practical
  advantage.

28
Thank you
29
Clinical Risk Management and Compression Bandage
Therapy

• Gail Powell
• Tissue Viability Nurse and Leg Ulcer Lead
• Bristol Primary Care Trust

30
Objectives of session

• Risk management overview
• Management of venous leg ulceration with
  compression bandaging and the associated risks
• Reducing the risk
• Positive outcomes

31
Risk Management

• Adverse health care events cannot be eliminated
  from complex modern health caredesigned to
  ensure that lessons from the past are used to
  reduce the risk to patients in the future.
• The cost of adverse events is increasing there
  is also a distressing similarity present in some
  of them.
• With clinical governance comes an opportunity to
  focus upon this problem.
• Specific types of adverse events are seen to
  repeat themselves at intervals, thus
  demonstrating that lessons have not been learnt.
• An Organisation with a memory.
• Department of Health.
• June 2000

32
Management with Compression Bandaging

• Considerable evidence to show that sustained
  high compression therapy improves ulcer healing
  and provides improved quality of life and cost
  benefits
• Stacey et al. The use of Compression Therapy
• in the Treatment of Venous Leg Ulcers
• a recommended Management Pathway.
• EWMA 20022(1)9-13

33
Associated risks

• Theoretical knowledge physiology and modes
  of action of bandage systems
• Patient assessment and diagnosis
• Appropriate management plan
• Application of compression bandage system
• Wound care/ Review

34
Untoward incident /Adverse event

• Definitions of adverse events and near misses
• Standardised format for reporting, with minimum
  data set
• Use of reporting forms.
• Root cause analysis (identifying causal or
  systems factors)
• Major existing adverse event reporting systems
• Promoting a culture of reporting and patient
  safety within NHS organisations, building on the
  transformation already under way as part of the
  clinical governance initiative.

• Inappropriate use of compression bandage systems,
  tissue damage, is this reportable, does this get
  reported
• Why did the incident occur? Theory, practice,
  education, patient concordance?
• What is a major event for your Trust?
  Inappropriate compression therapy leading to
  amputation
• Positive outcomes for patient, carer, clinician
  and NHS organisation.
• Building a safer NHS for patients
• Implementing an organisation with a memory.
• Department of Health. Feb 2007

35
Pressure Damage

• Not enough padding applied to the limb to
  shape and protect

36
Roles, responsibilities and actions

• Clinicians
• Maintain theoretical knowledge and practical
  skills
• Accept limitations to practice
• Report adverse events
• Action root cause analysis
• Reflect

• Industry
• Provide evidenced based compression bandage
  systems
• Support education and training initiatives
• Development of compression systems which reduce
  clinical risks

37
Reduces the risk
38
How?


Innovation that spreadsthe compression across 2
layers
39
ACCURATE SAFE and EFFECTIVE COMPRESSION
unstretched

• Ellipse becomes a circle
• correct stretch
• correct level of compression

unstretched
The etalonnage makes it simple and easy to apply
the correct pressure
40
How?

• Achieves therapeutic pressure levels, with the
  nurses ability to gauge thisenhanced by the
  etalonnage system (94 nurses achieved)
• Slim line and easy to apply, enhancing patient
  comfort and concordance
• Hanna, R.
• EWMA Conference
• May 2007

41
In conclusion

• The positive outcomes of good risk management in
  relation to compression bandaging therapy are
• Patient safety and comfort
• Achieving healing / appropriate management
• Improved clinician accountability
• Improved service delivery
• Reduced costs
• Maintain reputation of Trust and service

42

• Thank you